The Legacy of Harvey Cushing

A Portrait in History The Legacy of Harvey Cushing Venita Jay, MD, FRCPC t is a formidable task for any biographer to record all of I the achievements of Harvey William Cushing, com- monly known as the Father of American Neurosurgery. Regarded as the leading neurosurgeon of the 20th century, Cushing was a tireless investigator, dedicated teacher, proli®c writer, gifted artist, and ardent bibliophile. His name is known to every medical student and is immortalized in the well-known Cushing syndrome, Cushing disease, Cushing re¯ex, and Cushing ulcer. Cushing also left a lasting legacy in pathology with his work on the pituitary gland and brain tumors. Cushing launched neurosurgery as a distinct discipline and ®rmly established it as a separate specialty. Every phase of Cushing's career has been the subject of intense scrutiny, with extensive biographies detailing his college days at Yale, medical training at Harvard, surgical resi- dency at Johns Hopkins, and the years at Peter Bent Brigh- am and Yale. There are also several well-known biographies of Cushing, including those written by John F. Ful- ton, Elizabeth H. Thomson, and Justin F. Denzel. Born on April 8, 1869, in Cleveland, Ohio, Cushing was the youngest of 10 children, 7 of whom survived to ma- turity. His great-grandfather, grandfather, father, and old- er brother Ned were physicians. Cushing attended Yale College in New Haven, Conn, and graduated from that institution in 1891. While at Yale, Russell Chittenden encouraged in Cushing an interest in physiological chemis- try. Cushing greatly admired his father and his brother Ned. He followed in the family tradition and embarked on a medial career, joining Harvard Medical School in Boston, Mass. Cushing attended Harvard from 1891 to 1896 and received his medical degree in 1895. He completed his internship at Massachusetts General Hospital. During his medical school years, Cushing was a keen and observant student, who was able to recognize the im- Dr Harvey Cushing. Illustration by Venita Jay, MD, FRCPC. portance of new developments. Ether anesthesia had come into vogue, and medical students were called upon to ad- minister it. One patient anesthetized by Cushing died, esthesia that documented pulse and respiration. This which disturbed Cushing so much that he wanted to quit `èther chart,'' as it came to be called, worked well and medicine. Brooding over the tragedy and hoping that such revolutionized anesthesia practices. deaths could be prevented if vital signs were monitored, Cushing was also impressed with Roentgen's x-rays and he embarked on a new venture with fellow student Ernest was one of the ®rst to recognize their diagnostic potential. Amory Codman. Together, they developed a record of an- While still at Massachusetts General Hospital, Cushing personally took radiographs, made the emulsions, and developed the ®lms. His ®rst formal report on the use of x- Accepted for publication August 1, 2001. rays came in 1897, wherein he described 2 cases of gun- The author acknowledges that the general biographical overview presented does not necessarily include all of the accomplishments or shot wounds of the spine in which the bullet was localized achievements associated with the person discussed. Dr Jay welcomes through the use of x-rays. comments from readers concerning the `À Portrait in History'' section. In 1896, Cushing joined the Johns Hopkins Hospital in Reprints not available from the author. Baltimore, Md, as an assistant resident in surgery. He re- Arch Pathol Lab MedÐVol 125, December 2001 Harvey CushingÐJay 1539 mained at Johns Hopkins until 1912. His supervisor and Percival Bailey, he developed a pathogenetic classi®cation mentor was the legendary William Halsted. Halsted's sur- of gliomas. Cushing was also known for gasserian gan- gical technique, which emphasized gentle tissue handling, glionectomy for trigeminal neuralgia and transsphenoidal precise hemostasis, and attention to minute details, would surgery for pituitary tumors. Later, he turned to an intra- leave an indelible mark on Cushing, who emerged as a cranial approach for pituitary tumors. Other notable con- meticulous and extremely competent surgeon. Cushing's tributions by Cushing include innovations in hemostasis, careful approach to brain tumor surgery led to very low including use of muscle fragments and the ``silver clip,'' infection rates, superb operative results, and a substan- palliative decompressions for inoperable tumors, as well tially lower mortality rate. as innovations in electrosurgery. Cushing also advocated Sir William Osler, the ®rst professor of medicine at Hop- the use of physiological solutions in surgery and demon- kins, also profoundly in¯uenced Cushing. Osler and strated the detrimental effect of pure sodium chloride on Cushing became good friends, and Cushing adopted muscle and nerve preparations. He used radium for the many of Osler's traits, including a love of books. Cushing's treatment of gliomas, but was not favorably impressed deep admiration and respect for his mentor and friend with the results of brachytherapy. He also described ul- would culminate in a biography of Osler, titled The Life of ceration of the stomach, which frequently occurred with Sir William Osler, which won the 1926 Pulitzer Prize. intracranial tumors (Cushing ulcer). Cushing spent the 1900±1901 academic year in Europe, Cushing demonstrated that intracranial hemorrhage in where he was profoundly in¯uenced by some of the great- a newborn was not necessarily a hopeless situation that est minds in medicine and surgery. In Switzerland, he en- always culminated in cerebral palsy. In a 1905 report of 4 countered the famous surgeon Theodor Kocher and phys- infants with subdural hemorrhages who were operated iologist Hugo Kronecker, and performed the basic work on, Cushing described successful recovery in 2 cases. on the Cushing re¯ex (the rise of blood pressure with an Between 1908 and 1912, Cushing devoted himself to the increase in intracranial pressure). In 1901, Cushing's ep- study of the pituitary gland. The discovery of the pituitary och-making report on the regulation of blood pressure in gland as the controller of the body's hormonal balance was the setting of increased intracranial pressure was pub- an important milestone in endocrinology. Cushing rec- lished. Cushing stated that `à simple and de®nite law may ognized the states of hypopituitarism and hyperpituita- be established, namely, that an increase in intracranial ten- rism, and he had a keen interest in acromegaly and dwarf- sion occasions a rise in blood pressure which tends to ®nd ism. In 1912, he published the monograph The Pituitary a level slightly above that of the pressure exerted against Body and Its Disorders. Cushing described basophilic ade- the medulla.'' nomas of the pituitary associated with Cushing disease In Europe, Cushing also assisted physiologist Charles and described Cushing syndromeÐthe clinical effects of S. Sherrington of Liverpool, England, with mapping the hyperadrenalism. motor cortex of apes. While traveling in Pavia, Italy, Cush- In 1915, shortly after the outbreak of World War I, Cush- ing encountered the Riva-Rocci pneumatic cuff for mea- ing served in the Harvard Unit at Neuilly, France. From suring blood pressure, which he brought back to Harvard. 1917 to 1918, he was chief of a base hospital. One of Cush- As a result, blood pressure measurement was added to ing's major contributions while at the base hospital was the ether chart. In 1903, Cushing read his ®rst formal pa- to de®ne a logical and systematic approach to the care of per on routine determination of blood pressure during wounds involving the nervous system. surgery and in the clinic. While his paper was met with In addition to his Pulitzer Prize±winning biography of initial skepticism, time would prove him correct, and the Osler, Cushing left behind a rich legacy of masterful writ- sphygmomanometer would become an integral instru- ings. A proli®c writer, he produced several books and ment in medicine. monographs, and some 300 publications. On returning from Europe, Cushing started surgical Cushing took a keen interest in medical history and vis- practice at Johns Hopkins after getting the commitment ited antiquarian bookstores. He was encouraged in this from Halsted that he would be allowed to focus on the venture by Osler, whose collection was housed at McGill ``neurological side.'' Cushing established a very successful University in Montreal, Canada, while Cushing's collec- neurosurgical practice at Johns Hopkins. In 1910, he re- tion was housed at Yale. Cushing was particularly inter- ported a mortality rate of only 13% for brain tumors. Hal- ested in the work of Andreas Vesalius. sted also assigned Cushing to direct the Hunterian Lab- Cushing married Kate Crowell in 1902, and the couple oratory, where surgical investigations were performed. had 4 children. Their son, William, died in a car accident. Early in his career, Cushing was asked to contribute to Their 3 daughters went on to prominent social positions. the new 5-volume edition of Surgery, edited by William Max BroÈdel, the medical artist at Johns Hopkins, en- Williams Keen. Cushing prepared an impressive mono- couraged Cushing to develop his artistic talent. Immedi- graph of 276 pages and 154 illustrations, entitled Surgery ately after an operation, Cushing would sit down to drink of the Head. Published in 1908, this work became the single tea and make sketches from a surgeon's perspective. These most important neurosurgical text at the time and ®rmly drawings conveyed invaluable information about the op- established Cushing's reputation as a neurosurgeon. eration and became an integral part of his surgical reports. After Johns Hopkins, Cushing joined the Peter Bent Cushing retired from Harvard Medical School in 1933. Brigham Hospital in Boston, where he became surgeon- He then was named Sterling Professor of Neurology at in-chief. Cushing remained here from 1912 to 1933.

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